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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services 

          - [Document Identifier: CMS-10003, CMS-901A and D, CMS-9044, CMS-R-193 and CMS-10066] 

# AGENCY:

Centers for Medicare & Medicaid Services. 

In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services, is publishing the following summary of proposed collections for public comment. Interested persons are invited to send comments regarding this burden estimate or any other aspect of this collection of information, including any of the following subjects: (1) The necessity and utility of the proposed information collection for the proper performance of the Agency's function; (2) the accuracy of the estimated burden; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden. 

                        1.                         *Type of Information Collection Request:*                         Extension of a currently approved collection;                         *Title of Information Collection:*                         Notice of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) and supporting regulations in 42 CFR 422.568;                         *Use:*                         Section 1852(g)(1)(B) of the Statute requires Medicare Health organizations (Medicare Advantage, cost, and Health Care Prepayment Plans) to provide determinations to deny coverage (                        *i.e.*, medical services or payment) in writing and include a statement in understandable language of the reasons for the denial and a description of the reconsideration and appeals processes. These notices fulfill the regulatory requirement.                         *Form Number:*                         CMS-10003 (OMB#: 0938-0829);                         *Frequency:*                         Reporting: Yearly;                         *Affected Public:*                         Business or other for-profit and not-for-profit institutions;                         *Number of Respondents:*                         454;                         *Total Annual Responses:*                         105,138;                         *Total Annual Hours:*                         26285.                     

                        2.                         *Type of Information Collection Request:*                         Revision of a currently approved collection;                         *Title of Information Collection:*                         CMS Application for Federal Qualification (901A); CMS Medicare Agreement Application (901D) and Supporting Regulations in 42 CFR Section 417.143 and 422.6;                         *Use:*                         Prepaid health plans must meet certain regulatory requirements to be federally qualified health maintenance organizations or to enter into a contract with CMS to provide health benefits to Medicare beneficiaries. The application forms are used by CMS to collect information about a health plan to determine their compliance with Federal regulations.                         *Form Number:*                         CMS-901A and D (OMB#: 0938-0470);                         *Frequency:*                         Reporting: Once;                         *Affected Public:*                         Business or other for-profit and not-for-profit institutions;                         *Number of Respondents:*                         55;                         *Total Annual Responses:*                         55;                         *Total Annual Hours:*                         2,200.                     

                        3.                         *Type of Information Collection Request:*                         Revision of a currently approved collection;                         *Title of Information Collection:*                         Medicare ESRD Exceptions;                         *Use:*                         This information is collected in accordance with section 2145 of the Omnibus Budget Reconciliation Act of 1981 and section 623 of the Medicare Prescription Drug Improvement and Modernization Act of 2003. End Stage Renal Disease (ESRD) facilities can file for an exception to its composite payment rate. CMS uses the information submitted to determine whether an ESRD facility qualifies for a rate increase and the amount of the increase.                         *Form Number:*                         CMS-9044 (OMB#: 0938-0296);                         *Frequency:*                         Reporting: Occasionally;                         *Affected Public:*                         Business or other for-profit and not-for-profit institutions;                         *Number of Respondents:*                         10;                         *Total Annual Responses:*                         10;                         *Total Annual Hours:*                         400.                     

                        4.                         *Type of Information Collection Request:*                         Revision of a currently approved collection;                         *Title of Information Collection:*                         Medicare and Medicare Advantage Programs; Notification Procedures for Hospital Discharges—Important Message from Medicare                         *Use:*                         Requirements that hospitals notify beneficiaries in inpatient hospital settings of their rights as a hospital patient including their discharge appeal rights are referenced in Section 1866(a)(1)(M) of the Social Security Act (The Act). The authority for the right to an expedited determination is set forth at Section 1869(c)(3)(C)(iii)(III) of the Act. Under sections 42 CFR 405.1205 and 422.620, the hospital must deliver valid, written notice, the Important Message from Medicare (IM), of a patient's rights as a hospital patient including the discharge appeal rights, within 2 calendar days of admission. A follow-up copy of the signed IM is given again as far as possible in advance of discharge, but no more than 2 calendar days before. Follow-up notice is not required if the provision of the admission IM, falls within 2 calendar days of discharge.                     

                        Several changes are being proposed to the IM, including but not limited to the following: 1. Patient Information section: CMS removed the “Date of Notice” line. 2. Your Rights as Hospital Inpatient section: (a) There are several proposed clarifying language updates. (b) CMS added a bullet stating that the beneficiary can call the Quality Improvement Organization (QIO) for quality of care concerns based on information currently contained in the Medicare and You 2007 booklet. 3. Your Hospital Discharge and Medicare Appeal Rights section: CMS added a bullet stating that the beneficiary may call 1-800 Medicare and added supporting rational for when to call. 4. CMS added instructions for the beneficiary or representative to both sign and date the notice and, 5. CMS added an “Additional Information” space requesting that hospitals be able to add signature lines for hospital staff documentation.                         *Form Number:*                         CMS-R-193 (OMB#: 0938-0692);                         *Frequency:*                         Reporting: Yearly;                         *Affected Public:*                         Business or other for-profit and not-for-profit institutions;                         *Number of Respondents:*                         6000;                         *Total Annual Responses:*                         13,000,000;                         *Total Annual Hours:*                         3,250,000.                     

                        5.                         *Type of Information Collection Request:*                         New Collection;                         *Title of Information Collection:*                         Medicare and Medicare Advantage Programs; Notification Procedures for Hospital                               ( print page 17170)                            Discharges—Detailed Notice of Discharge;                         *Use:*                         The authority for the right to an expedited determination is set forth at Section 1869(c)(3)(C)(iii)(III) of the Social Security Act. This collection has been revised and now pertains to sections 42 CFR 405.1206 and 42 CFR 422.622. When a Quality Improvement Organization (QIO) notifies a hospital or Medicare Advantage (MA) organization that a beneficiary/enrollee has requested an expedited determination, the hospital or MA organization must deliver a detailed notice to the beneficiary/enrollee by noon of the day after the QIO's notification. In addition, the title has been revised, and the wording of the notice has been revised to more clearly convey the purpose of the notice. This revised notice fulfills the regulatory requirement;                         *Form Number:*                         CMS-10066 (OMB#: 0938-New);                         *Frequency:*                         Yearly;                         *Affected Public:*                         Business or other for-profit and not-for-profit institutions;                         *Number of Respondents:*                         6057;                         *Total Annual Responses:*                         130,000;                         *Total Annual Hours:*                         130,000.                     

                        To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS Web Site address at                         *http://www.cms.hhs.gov/​PaperworkReductionActof1995*, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to                         *Paperwork@cms.hhs.gov*, or call the Reports Clearance Office on (410) 786-1326.                     

Written comments and recommendations for the proposed information collections must be mailed or faxed within 30 days of this notice directly to the OMB desk officer: OMB Human Resources and Housing Branch, Attention: Carolyn Lovett, New Executive Office Building, Room 10235, Washington, DC 20503, Fax Number: (202) 395-6974. 

Dated: March 29, 2007. 

Michelle Shortt, 

Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs. 

[FR Doc. E7-6310 Filed 4-5-07; 8:45 am] 

BILLING CODE 4120-01-P